Columbia investigators begin public hearings into accident
BY WILLIAM HARWOOD
STORY WRITTEN FOR CBS NEWS "SPACE PLACE" & USED WITH PERMISSION
Posted: March 6, 2003
Shuttle program manager Ronald Dittemore, testifying today before the Columbia Accident Investigation Board, said safety is the agency's "lifeblood" and that his door is always open to any lower-level engineer who might be worried a safety issue is not being properly addressed.
Making his first public appearance since a round of high-profile news conferences immediately after the Columbia disaster, Dittemore said the system currently in place ensures critical information and safety concerns make their way up to senior managers and that this culture of safety is firmly in place across the manned space program.
"All I can say is we cultivate that culture," Dittemore said. "Anybody can come and walk in my office and say they've got a problem. Anybody can walk into any of our senior (managers') offices, say they have a problem and we will listen to then. I would be very disappointed if I found it to be otherwise."
But Harry McDonald, former director of NASA's Ames Research Center and chairman of a 1999 independent review of shuttle systems and maintenance practices, said the system can only work if it's based on the correct assumptions about what constitutes risk and if a system is in place to help managers access technical data.
"I have no concern at all that people like Ron Dittemore, presented with the facts, will make the right decision," McDonald said today. "No concern at all on that issue. The concern is presenting him with the facts and many of them are buried deep."
Many of the major recommendations made by McDonald's panel - the Space Shuttle Independent Assessment Team - were implemented by NASA. But others were not. McDonald said the agency continues to rely on archaic database technology that makes it difficult to quickly search for relevant test results across the program's history.
Case in point is concern about potential damage to the shuttle's protective heat shield tiles from impacts by foam insulation ripping free of the ship's external fuel tank during launch. A large piece of debris fell off Columbia's tank 81 seconds after liftoff Jan. 16 and struck the underside of orbiter's left wing.
Columbia was destroyed Feb. 1 when a breach in the left wing, possibly caused by the foam impact, allowed super-heated air to burn its way inside, ultimately triggering the shuttle's aerodynamic breakup 207,000 feet above Texas. All seven crew members were killed.
During the flight, engineers carried out an analysis based on earlier tests and extrapolated from that data to conclude that while Columbia's wing might suffer significant damage, there was no safety of flight issue.
But McDonald said problems with foam pulling off the tank were well known before launch and he questioned the process used to clear Columbia and other shuttles for flight in the first place. He questioned whether managers have ready access to data from flights, possibly years earlier, that could have a bearing on the current mission.
"What was the resolution of the foam issue on (flight) STS-87, what was the flight clearance process on STS-88, when the problem reoccurred on 88, how was it resolved for 90 and then 91? I mean, when someone like Dittemore goes and tries to make an assessment of what his risk is for the FRR, flight readiness review, the instant access to all that past history would have been valuable, incredibly valuable, I think. But we had not given that, in my view, sufficiently high priority."
After the hearing, he said the availability of more information to "people like Dittemore would result in a change in the culture, automatically. I think an engineer looking at that would say, you know this really isn't a very good extrapolation, from a square inch to a square foot."
A reporter said "but they did know that."
"Did Dittemore or people like that who were making the decision about flight readiness?" McDonald asked. "I mean, what had been communicated up to the flight readiness review team?"
McDonald praised the NASA workforce, telling the accident board his original team was "continually impressed with the skill, dedication, commitment and concern for astronaut safety by the entire shuttle workforce. And I see no reason to qualify either of these remarks today."
But he said any safety program is only as good as the assumptions that go into it.
"I think there's a basic flaw in the reasoning of many well-intentioned people and that is the concept that if you have a 1-in-100 risk of an event occuring, the event can occur on the first or the last, it's equal probability of when the event will occur. There seems to be the perception in the agency that if I've flown 20 times then the risk is less than if I've just flown once.
"And we were continually attempting to inform them that unless you've changed the risk positively, they still have the same issue even after 50 flights or 60 flights."
Several members of the Columbia Accident Investigation Board nodded in agreement.
"Now how do you address that issue?" McDonald went on. "Clearly, clearly, everybody in the agency has this desire and sense of importance, of the critical importance of safety. There's no issue about that. The question is how do you translate that into a safe and effective program? And that is very, very difficult given the complexity of the issue."
For his part, Dittemore articulately told the accident board he was confident the proper safeguards are, in fact, in place to ensure problems are properly dealt with, that managers have the data necessary to make the right decision and that individuals are encouraged to raise safety issues if they believe an issue is being overlooked.
"I think you have to cultivate a culture that allows everyone the opportunity to raise their hand and say they have a concern, to have the workforce feel no matter what position they are in in their organization that they can bring to management's attention an issue that they feel is significant, that management ought to address from a safety of flight point of view. The culture and the process have to be there. And I believe that is true today in our culture and our process."
"However, I must also state that we also cultivate a culture of second guessing, challenge, checks and balances and healthy tension," he said, speaking in the clear, direct manner that won praise during the initial post disaster news briefings. "We want our system, we want the people in our system, to challenge the assumptions. We want them to challenge the results of technical analysis or tests. And we do not feel threatened at all by that challenge. In fact, we believe it is healthy for us.
"And so when I hear about people in the system that are challenging and talking about particular analysis, that's what I want them to do. I want that to be part of our culture. But I also want them, if they believe that they have an issue, I want them to raise their hand and bring it forward to management.
"If they don't, given that I believe the culture is there and established for them to do so, then I must conclude that they do not believe strongly enough to bring it to management's attention, that it is something that they're in this challenging stage and they're doing a what-if type of discussion, which we also want them to do, to cover any event."
Speaking earlier, Jefferson Howell, director of the Johnson Space Center, told the accident board "everybody is totally intent on making this a safe activity at all levels, all the way to the end."
"I probably can't say it sufficiently how important safety is to every person who works at that center," he said. "It's a way of life. You can say it's number one. If we were fish, it's the ocean we swim in there. It's an attitude and so any time anybody raises that flag at any level, it gets people's attention very quickly. And people are going to take care of it."
While he said he was satisfied the system works properly at present, he said an ongoing concern for the future is the upcoming retirement of many senior civil servants with skills that will be hard to replace.
"I have a concern because a very large number of our civil servants are at the age where they may retire in the next several years," he said. "So I have that challenge in the future ahead of me. But as we speak right now, I'm very confident in the capabilities and skill levels of our people and our ability to support the shuttle program."
As for McDonald's concerns, Howell said the mission management team that oversees missions in progress and handles problems as they come up is a "very robust organization. This is really serious business and we commit a very robust engineering and operations team anytime we have a mission ongoing."
And he said pressure to continue building the international space station - the kind of schedule pressure another panel concluded played a role in the 1986 Challenger disaster - was not a factor in Columbia's demise or in the decision to launch any other mission.
"I've been accused of being too success oriented," he said. "That's sort of the nature of the beast at our center. One thing we have going for us, we have an administrator who is just beating upon us how important safety is and that should be our first primary consideration in everything we do. And he starts every meeting saying that and he ends every meeting saying that.
"We are very eager and excited about getting this station assembled," he said. "I'm excited about that and we're eager to get on with it and get that done. However, we understand the stakes and we are not going to do anything and press anybody to put aside any kind of quality assurance or safety issues."
Dittemore told the board NASA's morale "is generally pretty good considering the conditions we're operating under."
"It's been six weeks since we had an event that changed all our lives," he said. "And every day that goes by gets better as far as the workforce is concerned. As I mentioned to some folks earlier, the best therapy that we can do is be extremely engaged in solving this particular problem and everybody wants to be engaged in this effort. Without exception.
"Morale is good in that sense. There is an even more increased determination and a greater commitment to look very closely at the system and they are determined to identify if there is any weakness. It's broader than just what may be determined as the root cause. They're going to look to see if there's something else in the system that may have existed for many years, but now they will come back and make a recommendation to me that they'd like to make some improvements. Even though it may have nothing to do with the root cause."
The next public hearing is scheduled for March 17 and 18 in Houston.
"The role of the public hearings is to read things into the public record, to start at the beginning and we will then build upon that to get to the substantive issues," board Chairman Harold Gehman told reporters after today's hearing. "And then also to hear from experts that are not NASA people and kind of open our aperture a little bit.
"We thought all the witnesses were very forthcoming, they all answered our questions fully, nobody was defensive and so we were quite happy with the witnesses."
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